Special Medical Reports

Neurologic Group Develops Recommendations for Management of Epilepsy

SHARON SCOTT MOREY

Am Fam Physician. 1999 May 1;59(9):2648-2653.

Recommendations for the medical management of epilepsy have been developed by a group of 40 neurologists. The recommendations, published in the November 1998 issue of Neurology, come from a symposium convened at the 1998 annual meeting of the Southern Clinical Neurological Society. The report states that the recommendations are based on a review of the literature as well as actual clinical practice.

The recommendations are divided into sections that cover epilepsy in children and adolescents, adults, women and elderly persons. The following report summarizes the recommendations.

Epilepsy in Children and Adolescents

The recommendations state that a child with an initial single seizure should undergo evaluation to determine whether the seizure represents an epilepsy syndrome. A single seizure does not, however, signify the need for treatment. More intensive evaluation is required in children who have recurrent, unprovoked seizures. Among the studies that should be included in the evaluation are an electroencephalogram and imaging studies of the brain. According to the recommendations, high-resolution magnetic resonance imaging (MRI) is the preferred imaging study. If MRI is not available, computed tomography would be acceptable.

General treatment principles include initiation of therapy with one drug and the use of patient-specific factors to guide therapy. The expected duration of therapy depends on the epilepsy syndrome, the child's response to therapy and the child's age at the time of onset of seizures. In the section on epilepsy in children and adolescents, the recommendations describe the management approach for different types of seizure disorders in this group.

Idiopathic Benign Partial Seizures. The recommendations state that the symptoms should guide the selection of treatment and, in some children, drug therapy may not be necessary. If drug therapy is required, drug selection can be based on the safety and side effect profile. The recommendations state that almost all antiepileptic drugs effectively control partial seizures. The recommendations note that carbamazepine is one drug of choice for this type of seizure disorder. The newer antiepileptic agent gabapentin may also be another drug of choice because of its safety and low side effect profile. Barbiturates and benzodiazepines should not be used as first-line therapy.

Symptomatic Partial Epilepsy. Intensive evaluation, including assessment for early surgical intervention, is recommended for children with symptomatic partial epilepsy. The recommendations mention the antiepileptic agent gabapentin as a drug with a favorable side effect profile. According to the recommendations, many of the newer antiepileptic agents that are not yet approved for use in children may be tried in patients who are refractory to first-line treatment with standard agents.

Generalized Absence Epilepsy. While ethosuximide and valproate are most often used to control generalized absence epilepsy, the recommendations state that some of the newer antiepileptic agents may be an option if absence epilepsy is refractory to standard treatment or if the patient cannot tolerate standard therapy.

Simple Febrile Seizures. Clinical evaluation is recommended in children who have simple febrile seizures, but treatment is not usually required. The recommendations note that a diagnostic evaluation is indicated if complex febrile seizures have occurred.

Status Epilepticus. According to the recommendations, the risk of seizure recurrence is increased in children who initially present with seizures in the form of status epilepticus. The findings on the clinical evaluation dictate whether long-term therapy is required.

Epilepsy in Adults

The recommendations state that a thorough, detailed history and an electroencephalogram are the two most important aspects in the evaluation of an adult who presents with the onset of seizures. High-resolution MRI is recommended; the report states that computed tomography, which may have been performed during emergency evaluation of an adult presenting with a seizure, is not a substitute for an MRI of the brain.

According to the recommendations, phenytoin and valproate may offer the best control for the different forms of primary generalized epilepsy. Ethosuximide or valproate are considered appropriate for nonconvulsive absence syndromes. The report notes that the newer agents lamotrigine, topiramate and felbamate are effective in controlling primary generalized epilepsy and can be used if standard agents fail.

With respect to partial seizures, the recommendations note that phenytoin and carbamazepine are considered first-line agents.

Managing Poor Response. If the initial drug fails to control seizures, that agent should be discontinued and another antiepileptic agent tried. According to the recommendations, the patient should be reevaluated if monotherapy with two different agents fails to control the seizures. High-resolution MRI should be performed and electroencephalograms obtained again to exclude the development of a new disorder.

The report states that no clear recommendations can be made about the use of multidrug therapy in general or about which combinations of drugs might be helpful.

Epilepsy in Women

The recommendations discuss the importance of counseling women with epilepsy about pregnancy, family planning and lactation. Antiepileptic agents that induce the cytochrome P450 enzyme system pose an increased risk of contraceptive failure with hormonal agents.

Issues to discuss in prepregnancy counseling include the importance of seizure control and drug compliance, the need for folic acid supplementation, the risks of fetal loss and adverse fetal outcome, the need for prenatal diagnostic testing and the implications of child-care responsibilities on the seizure disorder. For example, sleep deprivation from taking care of an infant may have an effect on seizure control.

Epilepsy in Elderly Persons

According to the recommendations, a key aspect in the management of epilepsy in elderly persons is the decision of whether to treat the first-onset seizure or wait for recurrence. The report notes that the risk of recurrence after an initial seizure is approximately twice as high in older patients as in younger patients.

The recommendations describe a number of factors that would make an antiepileptic agent ideal for an elderly patient: These factors include once- or twice-daily doses; low cost; minimal or no side effects and no potential for major organ toxicity; few or no drug interactions; low protein binding; linear pharmacokinetics; little or no potential for allergic or other idiosyncratic reactions; and the availability of the drug in a parenteral formulation (see the accompanying table).

The recommendations note that certain qualities may be more important in some patients. For example, the qualities of gabapentin may make it a first-line drug for an elderly patient who has organ dysfunction or who is receiving other drug therapy. However, the cost of gabapentin and its dosing of three times daily may make it less attractive as a drug for a healthy elderly patient. According to the recommendations, antiepileptic agents that can be administered parenterally are the drugs of choice for acutely ill, frail individuals. In patients with dementia, the potential for cognitive side effects may be an important consideration.

The recommendations note that there have been no controlled clinical trials of the efficacy and safety of antiepileptic drugs in elderly patients. A Veterans Affairs study comparing gabapentin, lamotrigine and carbamazepine in this age group is currently under way.